Glomox is indicated for the treatment of the following infections in adults and children (see section 4.2, 4.4 and 5.1).

• Acute bacterial sinusitis

• Acute streptococcal tonsillitis and pharyngitis

• Acute exacerbations of chronic bronchitis

• Community acquired pneumonia

• Acute otitis media

• Acute cystitis

• Acute pyelonephritis

• Asymptomatic Bacteriuria in pregnancy

• Typhoid and paratyphoid fevers

• Dental abscess with spreading cellulitis

• Prosthetic joint infections

• Helicobacter pylori eradication

• Lyme disease

Glomox is also indicated for the prophylaxis of endocarditis. Consideration should be given to official guidance on the appropriate use of antibacterial agents.

The dose of Glomox that is selected to treat an individual infection should take into account:

• The expected pathogens and their likely susceptibility to antibacterial agents (see section 4.4)

• The severity and the site of infection

• The age, weight and renal function of the patient; as shown below

The duration of therapy should be determined by the type of infection and the response of the patient, and should generally be as short as possible. Some infections require longer periods of treatment (see section 4.4 regarding prolonged therapy).

Adults and children ≥40 kg

Children <40 kg

Children may be treated with Glomox capsules or suspensions.

Glomox Suspension is recommended for children under six months of age.

Children weighing 40kg or more should be prescribed the adult dosage.

Recommended doses:

Elderly

No dose adjustment is considered necessary.

Renal impairment

In patients receiving haemodialysis

Amoxicillin may be removed from the circulation by haemodialysis

In patients receiving peritoneal dialysis

Amoxicillin maximum 500mg/day

Hepatic impairment

Dose with caution and monitor hepatic function at regular intervals (see section 4.4 and 4.8).

Method of administration

Glomox is for oral use.

Absorption of Amoxicillin is impaired by food.

Therapy can be started parenterally according to the dosing recommendations of the intravenous formulation and continued with an oral preparation.

Swallow with water without opening capsule

Hypersensitivity reactions

Before initiating therapy with Amoxicillin, careful enquiry should be made concerning previous hypersensitivity reactions to penicillin and cephalosporins or other beta-lactam agents (see sections 4.3 and 4.8).

Serious and occasionally fatal hypersensitivity reactions (including anaphylactoid and severe cutaneous adverse reactions) have been reported in patients on penicillin therapy. These reactions are more likely to occur in individuals with a history of penicillin hypersensitivity and in atopic individuals. If an allergic reaction occurs, Amoxicillin therapy must be discontinued and appropriate alternative therapy instituted.

Non-susceptible microorganisms

Amoxicillin is not suitable for the treatment of some types of infection unless the pathogen is already documented and known to be susceptible or there is a very high likelihood that the pathogen would be suitable for treatment with Amoxicillin (see section 5.1). This particularly applies when considering the treatment of patients with urinary tract infections and severe infections of the ear, nose and throat.

Convulsions

Convulsions may occur in patients with impaired renal function or in those receiving high doses or in patients with predisposing factors (e.g. history of seizures, treated epilepsy or meningeal disorders (see section 4.8).

Renal impairment

In patients with renal impairment, the dose should be adjusted according to the degree of impairment (see section 4.2).

Skin reactions

The occurrence at the treatment initiation of a feverish generalised erythema associated with pustula may be a symptom of acute generalised exanthemous pustulosis (AGEP, see section 4.8). This reaction requires Amoxicillin discontinuation and contra-indicates any subsequent administration.

Amoxicillin should be avoided if infectious mononucleosis is suspected since the occurrence of a morbilliform rash has been associated with this condition following the use of Amoxicillin.

Patients with lymphatic leukaemia and possibly with HIV infection are particularly prone to developing erythematous rashes with Amoxicillin. Amoxicillin should be discontinued if a skin rash occurs.

Jarisch-Herxheimer reaction

The Jarisch-Herxheimer reaction has been seen following Amoxicillin treatment of Lyme disease (see section 4.8). It results directly from the bactericidal activity of Amoxicillin on the causative bacteria of Lyme disease, the spirochaete Borrelia burgdorferi. Patients should be reassured that this is a common and usually self-limiting consequence of antibiotic treatment of Lyme disease.

Overgrowth of non-susceptible microorganisms

Prolonged use of an anti-infective may result in the overgrowth of non-susceptible organisms (superinfection).

Antibiotic-associated colitis has been reported with nearly all antibacterial agents and may range in severity from mild to life threatening (see section 4.8). Therefore, it is important to consider this diagnosis in patients who present with diarrhoea during, or subsequent to, the administration of any antibiotics. Should antibiotic-associated colitis occur, Amoxicillin should immediately be discontinued, a physician consulted and an appropriate therapy initiated. Anti-peristaltic medicinal products are contra-indicated in this situation.

Prolonged therapy

Periodic assessment of organ system functions; including renal, hepatic and haematopoietic function is advisable during prolonged therapy. Elevated liver enzymes and changes in blood counts have been reported (see section 4.8)

Crystalluria

In patients with reduced urine output, crystalluria has been observed very rarely, predominantly with parenteral therapy. During the administration of high doses of Amoxicillin, it is advisable to maintain adequate fluid intake and urinary output in order to reduce the possibility of Amoxicillin crystalluria. In patients with bladder catheters, a regular check of patency should be maintained (see section 4.8 and 4.9).

Anticoagulants

Prolongation of prothrombin time has been reported rarely in patients receiving Amoxicillin. Appropriate monitoring should be undertaken when anticoagulants are prescribed concomitantly. Adjustments in the dose of oral anticoagulants may be necessary to maintain the desired level of anticoagulation (see section 4.5 and 4.8)

Interference with diagnostic tests

Elevated serum and urinary levels of Amoxicillin are likely to affect certain laboratory tests. Due to high urinary concentrations of Amoxicillin, false positive readings are common with chemical methods.

It is recommended that when testing for the presence of glucose in urine during Amoxicillin treatment, enzymatic glucose oxidase methods should be used.

The presence of Amoxicillin may distort assay results for oestriol in pregnant women

Oral anticoagulants

Oral anticoagulants and penicillin antibiotics have been widely used in practice without reports of interaction. However, in the literature there are rare cases of increased international normalised ratio in patients maintained on acenocoumarol or warfarin and prescribed a course of Amoxicillin. If co-administration is necessary, the prothrombin time or international normalised ratio should be carefully monitored with the addition or withdrawal of Amoxicillin (see sections 4.4 and 4.8).

Probenecid

Concomitant use of probenecid is not recommended. Probencid decreases the renal tubular secretion of amoxicilin. Concurrent use with Amoxicillin may result in increased and prolonged blood levels of Amoxicillin

Allopurinol

Concurrent administration of allopurinol during treatment with Amoxicillin can increase the likelihood of allergic skin reactions.

Tetracyclines

Tetracyclines and other bacteriostatic drugs may interfere with the bactericidal effects of Amoxicillin.

Methotrexate

Penicillins may reduce the excretion of methotrexate causing potential increase in toxicity

Pregnancy:

Animal studies do not indicate direct or indirect harmful effects with respect to reproductive toxicity. Limited data on the use of Amoxicillin during pregnancy in humans do not indicate an increased risk of congenital malformations. Amoxicillin may be used in pregnancy when the potential benefits outweigh the potential risks associated with treatment.

Breastfeeding:

Amoxicillin is excreted into breast milk in small quantities with the possible risk of sensitisation. Consequently, diarrhoea and fungus infection of the mucous membranes are possible in the breast-fed infant, so that breast-feeding might have to be discontinued. Amoxicillin should only be used during breast-feeding after benefit/risk assessment by the physician in charge.

Fertility:

There are no data on the effects of Amoxicillin on fertility in humans. Reproductive studies in animals have shown no effects on fertility.

No studies on the effects on the ability to drive and use machines have been performed. However, undesirable effects may occur (e.g. allergic reactions, dizziness, convulsions), which may influence the ability to drive and use machines (see section 4.8).

The following convention has been utilised for the classification of undesirable effects:

Very common (≥1/10),

Common (≥1/100 to <1/10),

Uncommon (≥1/1000 to <1/100),

Rare (≥1/10,000 to <1/1000),

Very rare (<1/10,000),

Not known (cannot be estimated from the available data)

The majority of side effects listed below are not unique to Amoxicillin and may occur when using other penicillins.

The most commonly reported adverse drug reactions (ADRs) are diarrhoea, nausea and skin rash.

Unless otherwise stated, the frequency of adverse events has been derived from more than 30 years of post-marketing reports.

Reporting of suspected adverse reactions

Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions at:

The National Pharmacovigilance Centre (NPC):

Fax: +966-11-205-7662

SFDA Call Center: 19999

E-mail: npc.drug@sfda.gov.sa

Website: https://ade.sfda.gov.sa

Symptoms and signs of overdose

Problems of overdosage with Amoxicillin are unlikely to occur. Gastrointestinal symptoms (such as nausea, vomiting and diarrhoea) and disturbances of the fluid and electrolyte balances may be evident. Amoxicillin crystalluria, in some cases leading to renal failure, has been observed (see Section 4.4). Convulsions may occur in patients with impaired renal function or in those receiving high doses (see section 4.4 and 4.8).

Treatment of intoxication

Gastrointestinal symptoms may be treated symptomatically, with attention to the water/electrolyte balance.

Amoxicillin can be removed from the circulation by haemodialysis

Pharmacotherapeutic group: penicillins with extended spectrum; ATC code: J01CA04

Mechanism of action

Amoxicillin is a semisynthetic penicillin (beta-lactam antibiotic) that inhibits one or more enzymes (often referred to as penicillin-binding proteins, PBPs) in the biosynthetic pathway of bactericidal peptidoglycan, which is an integral structural component of the bacterial cell wall. Inhibition of peptidoglycan synthesis leads to weakening of the cell wall, which is usually followed by cell lysis and death.

Amoxicillin is susceptible to degradation by beta-lactamases produced by resistant bacteria and therefore the spectrum of activity of Amoxicillin alone does not include organisms which produce these enzymes.

Pharmacokinetic/ pharmacodynamic relationship

The time above the minimum inhibitory concentration (T>MIC) is considered to be the major determinant of efficacy for Amoxicillin.

Mechanisms of resistance

The main mechanisms of resistance to Amoxicillin are:

• Inactivation by bacterial beta-lactamases

• Alteration of PBPs, which reduce the affinity of the antibacterial agent for the target.

Impermeability of bacteria or efflux pump mechanisms may cause or contribute to bacterial resistance, particularly in Gram-negative bacteria.

Breakpoints

MIC breakpoints for Amoxicillin are those of the European Committee on Antimicrobial Susceptibility Testing (EUCASAT) version 5.0.

The prevalence of resistance may vary geographically and with time for selected species, and local information on resistance is desirable, particularly when treating severe infections. As necessary, expert advice should be sought when the local prevalence of resistance is such that the utility of the agent in at least some types of infections is questionable.

Absorption

Amoxicillin fully dissociates in aqueous solution at physiological pH. Amoxicillin is stable in the acid gastric secretion and is rapidly absorbed from the gastrointestinal tract after oral administration. Following oral administration, Amoxicillin is approximately 70% bioavailable. The time to peak plasma concentration (T_max) is approximately one hour.

The pharmacokinetic results for a study, in which an Amoxicillin dose of 250 mg three times daily was administered in the fasting state to groups of healthy volunteers are presented below.

In the range 250 to 3000 the bioavailability is linear in proportion to dose (measured as C_max and AUC). The absorption is not influenced by simultaneous food intake.

Haemodialysis can be used for elimination of Amoxicillin.

Distribution

About 18% of total plasma Amoxicillin is bound to protein and the apparent volume of distribution is around 0.3 to 0.41/kg. Following intravenous administration, Amoxicillin has been found in gall bladder, abdominal tissue, skin, fat, muscle tissue, synovial and peritoneal fluids, bile and pus. Amoxicillin does not adequately distribute into the cerebrospinal fluid.

From animal studies there is no evidence for significant tissue retention of drug-derived material. Amoxicillin, like most penicillins, can be detected in breast milk (see section 4.6)

Amoxicillin has been shown to cross the placental barrier (see section 4.6).

Biotransformation

Amoxicillin is partly excreted in the urine as the inactive penicilloic acid in quantities equivalent to up to 10 to 25% of the initial dose.

Elimination

The major route of elimination for Amoxicillin is via the kidney.

Amoxicillin has a mean elimination half-life of approximately one hour and a mean total clearance of approximately 25 l/hour in healthy subjects. Approximately 60 to 70% of an orally administered dose is excreted unchanged in the urine during the first 6 hours after administration of a single 250mg or 500mg dose of Amoxicillin. Various studies have found the urinary excretion to be 50-85% for Amoxicillin over a 24 hour period.

Concomitant use of probenecid delays Amoxicillin excretion (see section 4.5)

Age

The elimination half-life of Amoxicillin is similar for children aged around 3 months to 2 years and older children and adults. For very young children (including preterm newborns) in the first week of life the interval of administration should not exceed twice daily administration due to immaturity of the renal pathway of elimination. In preterm infants with gestational age 26-33 weeks, the total body clearance after intravenous dosing of Amoxicillin, day 3 of life, ranged between 0.75 – 2 ml/min, very similar to the inuline clearance (GFR) in this population. Following oral administration, the absorption pattern and the bioavailability of Amoxicillin in small children may be different to that of adults. Because elderly patients are more likely to have decreased renal function, care should be taken in dose selection, and it may be useful to monitor renal function.

Gender

Following oral administration of Amoxicillin to healthy males and female subjects, gender has no significant impact on the pharmacokinetics of Amoxicillin.

Renal impairment

The total serum clearance of Amoxicillin decreases proportionately with decreasing renal function (see section 4.2 and 4.4).

Hepatic impairment

Hepatically impaired patients should be dosed with caution and hepatic function monitored at regular intervals.

There are no pre-clinical data of relevance to the prescriber which are additional to that already included in other sections of the SPC.

Sodium Lauryl Sulphate

Purified Talc

Magnesium Stearate

Composition of the hard empty Gelatin Capsules:

Hard empty gelatin capsules, Bovine origin, size "0EL" capsules, with a yellow colored body printed in black " GLOMOX 500" and the cap is colored brown printed in white "globalpharma"

Brown cap composition:

Iron oxide-red (1 %) and titanium oxide (0.33 %)

Yellow body composition: Iron oxide-yellow (1 %) and titanium oxide (1.67%)

Gelatin BSE free Q.S. to 100%

Water: 14.5% ± 1.5%

Not applicable.

Do not store above 30◦ C. Store in a dry place. Protect from light.

Glomox 500 Capsules: Aluminium–aluminium Blister packs of 20 capsules (10’s Blister x 2)

Not applicable